Healthcare Provider Details

I. General information

NPI: 1801925417
Provider Name (Legal Business Name): SUSAN GAIL MIX COUNSELING INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 YAKIMA AVE
TACOMA WA
98405-4457
US

IV. Provider business mailing address

1323 YAKIMA AVE
TACOMA WA
98405-4457
US

V. Phone/Fax

Practice location:
  • Phone: 253-502-2696
  • Fax: 253-502-2757
Mailing address:
  • Phone: 253-502-2696
  • Fax: 253-502-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRC00023513
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: